New Jersey Job Offers, which is best!!?!?

[podiatryinsearchof]

I am a current fellow and searching for jobs in the New Jersey area.
please give informative, expert opinions on which offers sound best, greatly appreciated!
* may I also add that a fellowship hardly seems worth it, as no ortho jobs want a podiatrist and no offers are above the “normally” offered pay scale

OPTION 1)
Small solo practice, doctor is about late 50s, been working solo for most of his career. Runs a practice with three consult rooms, in a smaller building which could use a face lift.
xray machine, which the physician takes himself. No DME in house.
I worked closely with this physician prior to fellowship, he has great confidence in me and would be a great mentor to work with.
he does forefoot surgery, so I would have run of the mill with rearfoot and forefoot surgeries, but I would have to work harder to obtain those patients. No ED call but I can take it myself if I want to. He is offering a lot of autonomy.
offer is about 100k base with minimal benefits package, possibly 30% on everything after 300k.
physician is looking to phase out of practice over next 5-7 years, to which it would transition to mine


OPTION 2: Large 12+ pod group. Many locations, with large administrative staff, DME, digital X-ray. Take every 3-4 saturdays, take call every 8 weeks and back up call every 14 weeks. Focus on recon surgery, easily obtain rearfoot and forefoot numbers. 120k base with amazing benefits package.
not as much autonomy, you are number 13 out of 13

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[619]

With option 1, you have a better chance of buying in or owning the practice down the road. And if he ever decides not to sell to you at a fair price, you will have no trouble opening up your own shop across town as you will have learnt a lot over the many years on how to run a small PP.

With option 2, you will probably never have the opportunity to partner or buy in. Lots of offices is also a red flag as you don't want to be driving to multiple offices (which always happens). Taking call too is another different topic. I don't mind taking call but it has be on my terms and only to see my patients. Not a big fan on rounding on other doctors patients.

If you work in a big group, you will always think you need all this administrative staff and what not. But working for a small solo doc, you get the autonomy, see things first hand and even be involved in decision making. Those experiences are invaluable and priceless. And I said, if he wants to sell the practice to you for a million dols, even half a mill, you will quickly realize you can open shop with about 100 grand.

Personallt, I will go with option 1

 

[heybrother]

#1
-How does he add you with 3 rooms?
-Is he willing to let you add DME?
-Old school solo docs tend to be incredibly set in their ways. I'm concerned about how efficient his office can be if he's taking x-rays. My colleague above has questioned how much administrative staff you need (I don't disagree) but you don't need to be taking x-rays.
-The above is the kind of thing where when you ask for a new nurse he may say - what do we need more staff for? We'll share this nurse and then he'll be losing it when his nurse is putting a dressing on your patients.
-People who are retiring in a few years aren't going to put a dime into their practice.
-What does autonomy mean when you say it? The first person is offering it, the second group is not. What does a 4 year trained physician and surgeon need oversight for? Are they going to come into treatment rooms with you? Listen to your "surgery sales pitch"? Scrub into your cases to watch how you cut? Are they going to give you shpiels and treatment plans for common conditions and expect you to dispense a certain amount of tolcylen and custom orthotics?
-What benefits does he provide? Is malpractice paid for - what amount, what type of insurance. Malpractice isn't actually a benefit by the way - its a necessity that they should be paying for.
-Is health insurance covered? To what extent ie. they pay for your premium but you pay for your copays, deductibles (presumably). Or no health insurance? If the job doesn't provide health insurance you'll have to buy it yourself on the market and you may be in for a surprise. I met with an old school pod once who told me - I don't buy my nurses health insurance - they all get it through their husbands. Cool story.
-Do you have a spouse/children? If your job covers your insurance premium you are still likely looking at $10-12K coming out of your pay check in premiums for your family.
-401k? Dental? Vision? CME $?
-When does your "bonus" - its not a bonus pay. As soon as you reach it or at the end of the year? You are aware you are making 33% up to $300K and 30% after it which is a paycut.
-Is the contract going to discuss the terms of his transition?
-Is there a non-compete?

I'm trying to write skeptical crappy things just to really make you think about how well you know this person. Can you actually see 2 doctors having busy schedule in this office.. The simple truth is this profession has perfectly nice people and sociopaths. The big thing here is - YOU MUST GET THE CONTRACT ASAP. Nothing is real until you see the contract. Don't conflate too much mentorship and jobs and money and things. Jobs sometimes love to "make friends" and get into your life - but the heart of this experience is to have a career and money. An unkind person might say - if this person respects you so much, why are they paying you so poorly.

What does transition mean? You buy his practice at a percentage of his and YOUR collections?

 

[619]

Also, why does the doc not have a DME license? Maybe no space for a DME room. DME is a big money maker btw.

Also for option 1, I wonder how do 2 docs will share 3 consult rooms and be busy. How will you hit bonus threshold. Don't count on rearfoot surgery to get you to bonus. You will make more money in clinic than spending 3 hours or more doing a triple or charcot recon or IM nail or ankle implant or whatever crazy surgeries people come up with.

For option 1, learn as much as you can and leave in year 2 or year 3 max to go solo. No reason to be an associate for 5-7 years before "transition time". The world is changing and the economy is changing, what if he changes his mind and decides to work till he is 70 and keep you as an associate forever. That is why you need to mentally prepare yourself going into option 1 that you are ready to go solo after 2-3 years.

 

[heybrother]

Also, why does the doc not have a DME license? Maybe no space for a DME room. DME is a big money maker btw.

Also for option 1, I wonder how do 2 docs will share 3 consult rooms and be busy. How will you hit bonus threshold. Don't count on rearfoot surgery to get you to bonus. You will make more money in clinic than spending 3 hours or more doing a triple or charcot recon or IM nail or ankle implant or whatever crazy surgeries people come up with.

For option 1, learn as much as you can and leave in year 2 or year 3 max to go solo. No reason to be an associate for 5-7 years before "transition time". The world is changing and the economy is changing, what if he changes his mind and decides to work till he is 70 and keep you as an associate forever. That is why you need to mentally prepare yourself going into option 1 that you are ready to go solo after 2-3 years.

I've got stories of this. 2 friends of mine both planned to go to private practices where someone was supposed to transition, retire, and then refused to when it came to hire the new associate until they were able to sweeten their deals. Meanwhile the residents-to-be-associates were sitting there wondering if they'd have a job or not.

Another guy once said to me - well even if we are partner's - I'll be 51% and you'll be 49% so I'll always decide when profits are distributed.

There's weird stories online ie. PM News job listings where people are trying to sell practices that have an associate. That always blows my mind.

 

[619]

I've got stories of this. 2 friends of mine both planned to go to private practices where someone was supposed to transition, retire, and then refused to when it came to hire the new associate until they were able to sweeten their deals. Meanwhile the residents-to-be-associates were sitting there wondering if they'd have a job or not.

Another guy once said to me - well even if we are partner's - I'll be 51% and you'll be 49% so I'll always decide when profits are distributed.

There's weird stories online ie. PM News job listings where people are trying to sell practices that have an associate. That always blows my mind.

I am always skeptical when I hear stories of a pod in his 50s (healthy and not dying soon) plans to retire and sell his practice in the next few years and wants to bring on an associate for a transition period. Except if it is clearly stated in the contract, very unlikely that will happen.

And even if he decides to walk way, he wants a million dollars to walk away.

Ask yourself, why would someone in his 50s or even 60s who have built a successful practice walk away from it. Except if it is a ticking time bomb or something bad lucking around, it never happens. Heck pods in their 70s are still holding on. Gotta love podiatry

 

[heybrother]

Agree with everything above. Unless you hurt your back you just keep working. You have an associate who is busting their tale while you take days off to play golf - even better.

Option #2

-I asked this above. What the hell does autonomy mean? My suspicion is it means telling you that a patient presenting with nail fungus needs (1) a PCR sent to the lab you own (2) dispensed $$$Tolcylen or whatever from your clinic (3) and a shoe anti-fungal wipe down sprayer. Maybe they go with you to the OR. Like I said above. You are 4 year trained. If you've done 50-100 ankles but want someone to scrub your first fibular nail with you that's different than shadowing all your cases.

-Travelling may grate on you especially if in the same day you go to multiple locations. Company car? Mileage?

-Call may grate on you. What does call mean? Hold the clinic phone? Or travel to plural hospitals to see inpatients, ED, etc? Is your schedule adjusted ie. clinic while you are on call? Is the group paid by the hospital to take call? Who owns the patients after you see them.

-A focus on surgery can mean a lot of things. If you somehow command all the foot and ankle referrals, the trauma, and the infections - cool. But the easiest way to generate a lot of surgery is to under treat patients and push surgery. I've got a long diatribe about this profession going in another window but a lot of podiatrists are desperate to be a SURGEON and the easiest way to get in the OR is telling everyone they need surgery. Similarly the easiest way to get certified is push surgery on patients who may not be ideal candidates because it serves your interest. I'm cynical, I'm being snarky but if you show up and conservatively work patients through your partners may be saying - I don't understand why you aren't in the OR.

-What does amazing benefits mean?

-What are the actual services you get from the administrative staff? They do casting for you? Dressings? They enter your coding? (will they change your coding?)

-Like you said. You are 13/13. You will be the first fired. Theoretically the last filled unless the whole point of bringing you on was to replace someone.

-You don't mention your bonus structure which makes me think its either non-existent or super complicated.

Get a contract asap to see what it says. They will already know what they like, want, expect. You'll have to get in line. Buy-in is probably a never or only some sort of complicated partial arrangement.

EDIT: Added. Do they own ORs/surgery centers. Will they expect you to get in line with their hardware, use their facilities.

 

[Feli]

Create more options... and yes, fellowship is fairly worthless unless you did a subpar residency or are doing fellowship with a truly great DPM or two.

The first solo office one should be a non-consideration. The guy is blowing smoke up your lab coat. They don't have the physical space, you won't get much for numbers for boards, and "retiring soon" or "slowing down" is a line from every senior owner doc talking to associates ever... as in since the dawn of time ever (usually, it's tied with phrases like "buy out" and "room to add more value with more surgery"). As was said, that job would be nothing but a fellowship in practice management (mediocre to poor practice mgmt). I'm sure he is a nice guy with good salesman skill, since that is the only quality that generally keeps pts coming to mediocre docs. Bid him thanks and start your real career... or go there for a year or two and learn for yourself, it's your life 🙂

The second one is worth consideration if you're married to that area, but it's probably a mill. You are just a cog and easily replaceable unless you have some elite talent the dozen other don't (RRA skill, hyper-productive, your dad owns the group, etc). Therefore, I would consider it only if the office is very well run (knowledgeable billers, managers, marketing and tech, trained staff and high volume efficiency, DME, etc) and if you will be paired with at least one or two highly skilled and motivated DPMs who you can learn from. Check their CVs and credentials and see how well the specific offices you'd be working in are run. In all likelihood, you can use it as a 2-4+ year bridge (make some money, get your ABFAS numbers to cert, learn how to bill and how an office runs), but I sure wouldn't plan on retiring there unless you want a 200-250k ceiling... maybe 300k if you work like a dog. GL man

 

[Utvolsdpm]

My advice is never work for another DPM. Ever. The latest slimy contract detail I’ve heard is a one year associate contract. I don’t know the salary offered (I assume the typical 80-10k) but if you leave before your one year is up you have to pay the podiatrist 150k!

 

[dtrack22]

physician is looking to phase out of practice over next 5-7 years, to which it would transition to mine

lol you mean he’ll ask you to buy his practice for a price you will not have agreed upon until 5-7 years from now?

And as someone else mentioned, you can’t both be busy with 3 treatment rooms without one of you working saturdays and expanded hours (ie 7am to 7pm every day where one works am the other pm and you overlap for an hour or two in the middle).

Also, why does the doc not have a DME license?

I don’t have a DME license. Don’t need it for commercial DME and medicare isn’t worth it any more with the crack down on 5-year same/similar device enforcement. So government DME is outsourced to donjoy and commercial DME I bill for. It’s not the craziest thing in the world though I agree it’s a good question to ask

get your ABFAS numbers to cert

Maybe. The OP better make sure every other recent grad in the group has gotten enough cases for RRA cert. I worked for 2 different podiatrists and never would have gotten RRA cert with the first and in a year and a half at the second was still a handful of different cases away from having RRA numbers. Plenty of podiatry group jobs where you won’t get the cases for RRA, though recent changes in the case diversity requirements could change that for some people.

but if you leave before your one year is up you have to pay the podiatrist 150k!

There is no way thats enforceable but it’s not surprising that a podiatrist would try this.



The OPs biggest problem is the whole New Jersey part...

 

[Startingover123]

I am a current fellow and searching for jobs in the New Jersey area.
please give informative, expert opinions on which offers sound best, greatly appreciated!
* may I also add that a fellowship hardly seems worth it, as no ortho jobs want a podiatrist and no offers are above the “normally” offered pay scale

OPTION 1)
Small solo practice, doctor is about late 50s, been working solo for most of his career. Runs a practice with three consult rooms, in a smaller building which could use a face lift.
xray machine, which the physician takes himself. No DME in house.
I worked closely with this physician prior to fellowship, he has great confidence in me and would be a great mentor to work with.
he does forefoot surgery, so I would have run of the mill with rearfoot and forefoot surgeries, but I would have to work harder to obtain those patients. No ED call but I can take it myself if I want to. He is offering a lot of autonomy.
offer is about 100k base with minimal benefits package, possibly 30% on everything after 300k.
physician is looking to phase out of practice over next 5-7 years, to which it would transition to mine


OPTION 2: Large 12+ pod group. Many locations, with large administrative staff, DME, digital X-ray. Take every 3-4 saturdays, take call every 8 weeks and back up call every 14 weeks. Focus on recon surgery, easily obtain rearfoot and forefoot numbers. 120k base with amazing benefits package.
not as much autonomy, you are number 13 out of 13

Does option two come with a bonus structure?

 

[GreenHousePub]

These are the options for someone who is "fellowship trained?" What was the point of this fellowship.

Option 1: he will ask you for a million dollars for the purchase price when that transition comes. I guarantee you it will be at least 1 million.
You will get no rearfoot surgeries and it will be up to him to decide if you get any surgery at all.
With only three office rooms shared with two people, you will never hit your bonus.
Walk away from this.

Option 2: Why don't you do that one. Still not anything special.

Both of those options are absolute dog****.

 

[josebiwasabi]

There's no way that these can be your best options, both sound like garbage to me.

Surely through your residency or fellowship attendings you can find better connections/offers?

And in terms of pay, it's up to you to explain the value of your fellowship to the practice. Saying that you are fellowship trained does not automatically entitle you to an additional 50k base salary.

The value of your fellowship is not that you have 4 years of training or that you did an additional 600 surgeries. You need to show them what is unique about your training vs a typical pgy3 and how that translates to greater production and revenue for the practice.

 

[DYK343]

Another crappy northeast contract(s). Who would have thought?

(see my prior posts)

 

[CutsWithFury]

New Jersey. Great state for living especially if you are close to the beach towns. Great food. Great music scene. Lots to do.

For podiatry...meh

NJ is so bizarre. They have a GREAT state scope but it’s filled with DPMs who shouldn’t be operating.

The NJ trend is that a lot of DPMs tend to do cases with each other because they are just comfortable with two podiatrists in the room doing a bunionectomy instead of one. It’s sad.

 

[podiatryinsearchof]

With option 1, you have a better chance of buying in or owning the practice down the road. And if he ever decides not to sell to you at a fair price, you will have no trouble opening up your own shop across town as you will have learnt a lot over the many years on how to run a small PP.

With option 2, you will probably never have the opportunity to partner or buy in. Lots of offices is also a red flag as you don't want to be driving to multiple offices (which always happens). Taking call too is another different topic. I don't mind taking call but it has be on my terms and only to see my patients. Not a big fan on rounding on other doctors patients.

If you work in a big group, you will always think you need all this administrative staff and what not. But working for a small solo doc, you get the autonomy, see things first hand and even be involved in decision making. Those experiences are invaluable and priceless. And I said, if he wants to sell the practice to you for a million dols, even half a mill, you will quickly realize you can open shop with about 100 grand.

Personallt, I will go with option 1

Awesome feedback! Appreciate it

 

[podiatryinsearchof]

OP here:

- yes option 2 has a bonus structure, which I can’t quite recall off the top of my head. Malpractice, health insurance, and car mileage/phone service coverage

- agreed that NJ sucks, seems like no one sees any value in being fellowship trained even though I am bringing added skills to both practices that they are lacking, I.e TARs and sports med

There is an OPTIO 3) which is in southeast PA
Three pod group, one pod is leaving and they are looking to replace him. There’s a no compete of 15 miles so they hope his patients will stay with the practice. Nice facilities, digital X-ray and EMR, MAs take X-rays for you and they have an NP on staff for Med clearance. They do own a surgery center in the office, which are basically two procedure rooms fitted out to be ORs. For forefoot it seems they would prefer that but seem supportive of allowing hopsital cases for MIS or other specific hardware. They take no call.
offering base 100k with 25% after every 30k per month. Insurance included

 

[Pronation]

With option 1, you have a better chance of buying in or owning the practice down the road. And if he ever decides not to sell to you at a fair price, you will have no trouble opening up your own shop across town as you will have learnt a lot over the many years on how to run a small PP.

With option 2, you will probably never have the opportunity to partner or buy in. Lots of offices is also a red flag as you don't want to be driving to multiple offices (which always happens). Taking call too is another different topic. I don't mind taking call but it has be on my terms and only to see my patients. Not a big fan on rounding on other doctors patients.

If you work in a big group, you will always think you need all this administrative staff and what not. But working for a small solo doc, you get the autonomy, see things first hand and even be involved in decision making. Those experiences are invaluable and priceless. And I said, if he wants to sell the practice to you for a million dols, even half a mill, you will quickly realize you can open shop with about 100 grand.

Personallt, I will go with option 1

This is such terrible advice... hopefully OP pays closer attention to all the others that posted who have some common sense...

 

[podiatryinsearchof]

This is such terrible advice... hopefully OP pays closer attention to all the others that posted who have some common sense...

????

 

[HardRoadPaved]

no one sees any value in being fellowship trained even though I am bringing added skills to both practices that they are lacking, I.e TARs and sports med

Because going to the OR doesnt make them as much as youd think. 27702 CPT (TAR) is $1100 medicare reimbursement for Medicare in NJ. In the grand scheme they pretty much lost half/whole day of production from you for that so if you dont have multiple docs at a location then it hurts even more. Day in the office shooting out a few orthotics and doing ingrown toenails/warts/basic wounds will be much more profitable.

Sorry but those "added skills" doesnt always translate to profit.

Edit: and also what happens when there is post-op management.... do these people want to take on your headaches? what if you leave them with a lousy call weekend of your patient in pain or the hospital bugging them for orders?

 

[heybrother]

Because going to the OR doesnt make them as much as youd think. 27702 CPT (TAR) is $1100 medicare reimbursement for Medicare in NJ. In the grand scheme they pretty much lost half/whole day of production from you for that so if you dont have multiple docs at a location then it hurts even more. Day in the office shooting out a few orthotics and doing ingrown toenails/warts/basic wounds will be much more profitable.

Sorry but those "added skills" doesnt always translate to profit.

Edit: and also what happens when there is post-op management.... do these people want to take on your headaches? what if you leave them with a lousy call weekend of your patient in pain or the hospital bugging them for orders?

Apart from the $$$ really not being there - I'm skeptical the frequency this intervention occurs is really that high. My residency was in uncontested territory - if it was foot and ankle we basically we got it or we had passed on it. Made up statistic but I felt like rearfoot arthritis was 20x as common as ankle arthritis.

A friend of mine told me they knew someone who did a TAR fellowship, went to a big town and didn't see a single patient in a 2 year time that was a good candidate for a TAR. Now - that gets into a lot of territory - referral sources, competition, etc.

The marketing of rearfoot to me seems tricky:

(1) A pod practice that doesn't surgically treat rearfoot but manages non-operatively rearfoot/ankle and then ultimately refers a portion of it on for surgery. Perhaps they see value in keeping it in house. How much can there really be though.
(2) A pod practice that does rearfoot surgery and wants someone else to do it. Here - you can have all these cases when they come in.
(3) A hospital job where you just want it to be clear to them you can do whatever.
(4) An orthopedics group that doesn't have a foot and ankle person, where others are having to do ankle fusions and not enjoying it, that wants to market TAR as a new service, and also doesn't hate podiatry. Very common.

EDIT: Let's say you are a legit, tried and true TAR and ankle fusion surgeon. You move to a new area. The other doctors in your area are only doing ankle fusions. Do you think they will refer their patients on to you so you can evaluate them for TAR. Would an orthopedist say - now you have ankle arthritis. Why don't we let the new podiatrist work you up for a joint replacement as opposed to me doing your fusion? Would a competing podiatrist refer to you? Local dynamics may vary. I don't know what New Jersey is like.

 

[CutsWithFury]

Apart from the $$$ really not being there - I'm skeptical the frequency this intervention occurs is really that high. My residency was in uncontested territory - if it was foot and ankle we basically we got it or we had passed on it. Made up statistic but I felt like rearfoot arthritis was 20x as common as ankle arthritis.

A friend of mine told me they knew someone who did a TAR fellowship, went to a big town and didn't see a single patient in a 2 year time that was a good candidate for a TAR. Now - that gets into a lot of territory - referral sources, competition, etc.

The marketing of rearfoot to me seems tricky:

(1) A pod practice that doesn't surgically treat rearfoot but manages non-operatively rearfoot/ankle and then ultimately refers a portion of it on for surgery. Perhaps they see value in keeping it in house. How much can there really be though.
(2) A pod practice that does rearfoot surgery and wants someone else to do it. Here - you can have all these cases when they come in.
(3) A hospital job where you just want it to be clear to them you can do whatever.
(4) An orthopedics group that doesn't have a foot and ankle person, where others are having to do ankle fusions and not enjoying it, that wants to market TAR as a new service, and also doesn't hate podiatry. Very common.

EDIT: Let's say you are a legit, tried and true TAR and ankle fusion surgeon. You move to a new area. The other doctors in your area are only doing ankle fusions. Do you think they will refer their patients on to you so you can evaluate them for TAR. Would an orthopedist say - now you have ankle arthritis. Why don't we let the new podiatrist work you up for a joint replacement as opposed to me doing your fusion? Would a competing podiatrist refer to you? Local dynamics may vary. I don't know what New Jersey is like.

Good stuff

On a side note I think being fellowship trained and joining a private practice podiatry group is a complete waste of your training and time. Go ortho group or hospital employed or bust. If you can't do that then you are better off starting your own practice and building it the way you want. Market yourself the way you want. Control the practice from the ground up rather than dealing with or changing the practice dynamics that has been set up by the TFPs who hired you.

 

[air bud]

Good stuff

On a side note I think being fellowship trained and joining a private practice podiatry group is a complete waste of your training and time. Go ortho group or hospital employed or bust. If you can't do that then you are better off starting your own practice and building it the way you want. Market yourself the way you want. Control the practice from the ground up rather than dealing with or changing the practice dynamics that has been set up by the TFPs who hired you.

I have a friend trained at a well known fellowship. Super great guy and smart. Bought out some TFPs. Even he will admit it takes time to change the culture. Do you trust the process? Or blow it all up and start from scratch?

 

[heybrother]

OP here:

- yes option 2 has a bonus structure, which I can’t quite recall off the top of my head. Malpractice, health insurance, and car mileage/phone service coverage

- agreed that NJ sucks, seems like no one sees any value in being fellowship trained even though I am bringing added skills to both practices that they are lacking, I.e TARs and sports med

There is an OPTIO 3) which is in southeast PA
Three pod group, one pod is leaving and they are looking to replace him. There’s a no compete of 15 miles so they hope his patients will stay with the practice. Nice facilities, digital X-ray and EMR, MAs take X-rays for you and they have an NP on staff for Med clearance. They do own a surgery center in the office, which are basically two procedure rooms fitted out to be ORs. For forefoot it seems they would prefer that but seem supportive of allowing hopsital cases for MIS or other specific hardware. They take no call.
offering base 100k with 25% after every 30k per month. Insurance included

#3
-One pod is leaving. A long time member of the practice or the associate who is leaving because it sucks?

-You will likely be asked to sign a similar non-compete if you leave in the future. The original signer may be reading this forum reading dtrack's posts and wondering - is my non-compete enforceable. Will they enforce the non-compete against me. What I'm really saying here is - how big is this town. If you put down roots and you sign a 15 mile non-compete you probably won't be in the town anymore if its enforceable.

-Why do they have an NP on staff/what else does the NP do? Is this group part of something bigger or do they actually employ an NP to medically clear their patients? Who signs off on the NP's notes. I've never seen anything like this so maybe its common in other parts of the country. Near where I trained an orthopedic group employed an internist for pre-op evaluations and workup.

-Are these procedure rooms or are they also trying to bill this out for the facility fee? I don't claim to know all the dynamics of this but I can't help but wonder if they'll be expecting everything you do to be done with a k-wire in the office. I'm all about trying to explore reasonable and rationale procedures that we could be doing in the clinic to save patients outpatient surgery center costs but this may be their big expectation of you of you regardless of what they say.

-Setting up "every month separate threshold" system is just an overly complicated way to deny you a bonus which is already very low.

-100 / 30*12 = 27.7%. Followed by 25% which is awful.

Most people would simply reject this offer just based on the collections percentage.

 

[619]

This is such terrible advice... hopefully OP pays closer attention to all the others that posted who have some common sense.

Oh Mr or Mrs common sense, what advice do you have to offer?? I see none from you on this tread.

Everyone saying OP should join ortho group, MSG, hospital group or start a practice from scratch. I am sure all options are very easy as it sounds. A walk in the park right!!!

Everyone bashing OP for doing a fellowship? How is that a solution to his questions.

My answer was based between those 2 options and being unemployed. Or even the new option 3 is not far off from the first 2 options. Just to show that podiatry is the same where ever you go.

I will still stick with my advice, where ever OP goes, he will get screwed either way. Therefore, learn as much as you can, live like a resident (don't buy a house or take out a car loan) and save a lot of cash, then open up your own practice after 2-3 years as an associate. This is a marathon, not a sprint.

It is a ok to take out a small healthcare business loan to open a solo practice even with existing student loans.

OP knows his personal situation and hopefully he makes a good decision. Good luck

 

[CutsWithFury]

Oh Mr or Mrs common sense, what advice do you have to offer?? I see none from you on this tread.

Everyone saying OP should join ortho group, MSG, hospital group or start a practice from scratch. I am sure all options are very easy as it sounds. A walk in the park right!!!

Everyone bashing OP for doing a fellowship? How is that a solution to his questions.

My answer was based between those 2 options and being unemployed. Or even the new option 3 is not far off from the first 2 options. Just to show that podiatry is the same where ever you go.

I will still stick with my advice, where ever OP goes, he will get screwed either way. Therefore, learn as much as you can, live like a resident (don't buy a house or take out a car loan) and save a lot of cash, then open up your own practice after 2-3 years as an associate. This is a marathon, not a sprint.

It is a ok to take out a small healthcare business loan to open a solo practice even with existing student loans.

OP knows his personal situation and hopefully he makes a good decision. Good luck

Nobody is bashing the OP for doing a fellowship...

 

[podiatryinsearchof]

this job search is so incredibly disheartening, and getting even more so with this feedback. It seems like any offers in receiving are sub-par.
In NJ, all ortho groups currently hiring for foot and ankle positions Specify they are only looking to hire orthopedic foot and ankle surgeons. I’ve even sent my CV to these practices and have heard nothing back.

 

[Startingover123]

this job search is so incredibly disheartening, and getting even more so with this feedback. It seems like any offers in receiving are sub-par.
In NJ, all ortho groups currently hiring for foot and ankle positions Specify they are only looking to hire orthopedic foot and ankle surgeons. I’ve even sent my CV to these practices and have heard nothing back.

What do you think you can potentially make (salary plus bonus) for option two and three? Have you looked at jobs nationally or just the northeast?

 

[dtrack22]

offering base 100k with 25% after every 30k per month. Insurance included

As was just mentioned. $100k base for $360k in collections (kind of, since it appears to be calculated monthly you could technically start getting a cut or collections before dollar number 360,001 comes in) is a bigger % than your 25% production incentive. So you are taking a pay cut once you out-produce your base contract. There is no reason to get less of every dollar you bring in after you cover your base salary. None.

all ortho groups currently hiring for foot and ankle positions Specify they are only looking to hire orthopedic foot and ankle surgeons

This is common everywhere. I’m sure there is plenty of bias but it’s largely MD/DO only for call reasons. Ortho groups don’t want to hire someone who can’t offload their call schedule. If they are 1:6 they want to be 1:7, not 1:6 with someone who can take the foot and ankle pathology which typically doesn’t require them to come in after hours for any ways. An ortho group where I live (not where I work) recently hired an F/A ortho and he only has 50% of his practice as pure foot and ankle, at least that was the initial “guarantee” from the ortho group. But they wanted him to offload call and soak up some trauma, not just foot and ankle pathology. He’s more valuable to that group than any of us could be. So even if there isn’t a podiatry-hatred thing going on, you’ll always have ortho groups who have no desire to hire a podiatrist. And it makes perfect sense.

 

[podiatryinsearchof]

As was just mentioned. $100k base for $360k in collections (kind of, since it appears to be calculated monthly you could technically start getting a cut or collections before dollar number 360,001 comes in) is a bigger % than your 25% production incentive. So you are taking a pay cut once you out-produce your base contract. There is no reason to get less of every dollar you bring in after you cover your base salary. None.


This is common everywhere. I’m sure there is plenty of bias but it’s largely MD/DO only for call reasons. Ortho groups don’t want to hire someone who can’t offload their fall schedule. If they are 1:6 they want to be 1:7, not 1:6 with someone who can take the foot and ankle pathology which typically doesn’t require them to come in after hours for any ways. An ortho group where I live (not where I work) recently hired an F/A ortho and he only has 50% of his practice as pure foot and ankle, at least that was the initial “guarantee” from the ortho group. But they wanted him to offload call and soak up some trauma, not just foot and ankle pathology. He’s more valuable to that group than any of us could be. So even if there isn’t a podiatry-hatred thing going on, you’ll always have ortho groups who have no desire to hire a podiatrist. And it makes perfect sense.

What would be your advice as a counter to that bonus structure/incentive plan to make it more “worthwhile”?

 

[podiatryinsearchof]

What do you think you can potentially make (salary plus bonus) for option two and three? Have you looked at jobs nationally or just the northeast?

Really sticking to NJ/PA area

 

[heybrother]

A Podiatry Tale

A hardware rep asked me if I had a moment to stop by a lab he was doing for a F&A ortho . His boss was there and he wanted me to meet him. It was at a small hospital. Some sort of head honcho nurse was there making sure they'd have what they needed. The hardware rep introduced me as a foot and ankle surgeon. The nurse's eyes took on this incredible light when she heard these words. A FOOT AND ANKLE SURGEON she said. How long had I been in town? Who did I work for? Did I know their hospital was honored to have TWO foot and ankle surgeons.

Me: I apologize. I take it from your flattering level of interest that you believe me to be an orthopedic surgeon. I am a podiatrist.
Nurse: Oooooooooooooooooooooooooooh. Well we have an outpatient center across the street where some podiatrists operate.

The ortho was late. Was washing out a hip.

I still laugh about it.

 

[dtrack22]

What would be your advice as a counter to that bonus structure/incentive plan to make it more “worthwhile”?

Your base pay is only around 28% of collections (bad). Your production incentive is 25% (worse). If it is a podiatry group they will not entertain this but I would tell them that your base needs to be $120k with a $30k per month production incentive (ie 33%) and your % of collections once you’ve hit your production number needs to be 40% (figuring 35% is the minimum you should take).

Financially this is not unreasonable for the practice, and if it is I would question their management skills. Or 25-30% collections (what they are offering now) better come with fully covered health benefits AND collections need to include DME AND you better have your marketing done for you (they need to pay anytime you want to have a lunch for a referring providers office, or a new potential referral source) AND you should get a scribe AND there better be a couple thousand dollars in CME and a minimum of 14 days PTO AND probably a few other things I’m forgetting...

 

[heybrother]

You cannot take a 25% job. Try dtrack's advice. Ask for what you need. Perhaps they turn it into a plain old podiatry turd at 30%. The worst they can say is no.

Fun story. I look back at people I interviewed with forever ago. Of the three I most recently looked at:

-One has a new employee. I interviewed with them like 2 years ago and they didn't have someone until a month ago. Back when I interviewed they claimed they'd gotten like 100 apps and were going to interview 30 people.
-One told me they were phone interviewing like 30 people, were going to have 10-12 people fly in and would pick someone. I got offered an interview and told them I wouldn't waste my time flying in unless I knew the projected salary range. They didn't tell me. I didn't interview. They never hired anyone.
-One had been looking for an employee for 5 years writing to residencies and such. I saw 6 months ago they had someone listed on their website and when I looked a few months later they were already gone. Max time they had an associate was like 2 months.

These aren't opportunities. They fill out of desperation. Its entirely possible that they won't ever fill the spot.

 

[619]

Every one has great ideas about negotiation and what not. However the first rule of negotiation is the ability to walk away.

If OP has no other contract IN HAND (not verbal offer), then trying to negotiate for what is "fair" is fruitless. The more contract you have in hand, then the more upper hand (or foot) you have to negotiate.

If you are looking for the perfect job and what is "fair", then you will end up "over qualified" with a fellowship training and unemployed at the end of the day. Most offers are not going to be fair coming out. As I said, it is a marathon not a sprint. Just my 2 cents.

 

[HardRoadPaved]

Every one has great ideas about negotiation and what not. However the first rule of negotiation is the ability to walk away.

If OP has no other contract IN HAND (not verbal offer), then trying to negotiate for what is "fair" is fruitless. The more contract you have in hand, then the more upper hand (or foot) you have to negotiate.

If you are looking for the perfect job and what is "fair", then you will end up "over qualified" with a fellowship training and unemployed at the end of the day. Most offers are not going to be fair coming out. As I said, it is a marathon not a sprint. Just my 2 cents.

Couldn't agree more. Honestly good luck negotiating an offer. Honestly I think the old guard is stuck in its ways of 75-125k base + some multiplier/base% that doesnt reward fairly. Then all the other employers see these ads and go "well that's what the market is."

 

[underwood]

I’m a current resident and keep up with these forums, especially job threads. How common is it to ask for straight 35-40 collections? No base. How do practice owners feel about this type of contract?

 

[heybrother]

The OP knows more about his situation than we do. Test the water with none. The water with some. Test the water with all. His best interest probably lines up somewhere along a spectrum. He's spoken to these people. He maybe knows what is hot and what is cold.

-His mentor's office seems impossible.
-The mill might or might not have promise.
-He could test the water's with the Penn people or not.

Anything he's pursuing he needs to get a contract on. We can talk about not negotiating but it is possible to sign a financially destructive contract that burns you after you leave like how the non-compete is set up.

We're just giving a variety of ideas. I'm sure this person already has a mom who is telling them that 100K will be wonderful.

 

[619]

I’m a current resident and keep up with these forums, especially job threads. How common is it to ask for straight 35-40 collections? No base. How do practice owners feel about this type of contract?

Let us define this first: Straight collections more likely means you are working as an independent contractor/1099.

Straight collections only works for someone who is already practicing, already credentialed with insurance companies and have a patient base/reputation. This person is already proven with years of experience so a practice can bring him/her on board and they negotiate a straight % of collection. Hardly will they do this with a fresh grad out of residency.

Coming fresh out of residency to do straight collections means you are willing to go months (>6 months) without income, it takes 3-6 months to get fully credentialed with all the insurance companies, then build your patient base, then perfect your billing etc. Coming out of residency and asking for 35-40% of collections is a long shot. Why would they agree to that when they can easily hire a fresh grad for a fraction of that. Except if the practice is in a remote place in the middle of no where and they are desperate. Then again, do they have the volume of patients for you to make a good income.

Overall I believe there is money in podiatry. However to get there, it is a marathon not a sprint

 

[air bud]

Let us define this first: Straight collections more likely means you are working as an independent contractor/1099.

Straight collections only works for someone who is already practicing, already credentialed with insurance companies and have a patient base/reputation. This person is already proven with years of experience so a practice can bring him/her on board and they negotiate a straight % of collection. Hardly will they do this with a fresh grad out of residency.

Coming fresh out of residency to do straight collections means you are willing to go months (>6 months) without income, it takes 3-6 months to get fully credentialed with all the insurance companies, then build your patient base, then perfect your billing etc. Coming out of residency and asking for 35-40% of collections is a long shot. Why would they agree to that when they can easily hire a fresh grad for a fraction of that. Except if the practice is in a remote place in the middle of no where and they are desperate. Then again, do they have the volume of patients for you to make a good income.

Overall I believe there is money in podiatry. However to get there, it is a marathon not a sprint

5k or 10k maybe. Not a marathon.

 

[dtrack22]

However the first rule of negotiation is the ability to walk away.

Yeah you need to be able to say “no” to a bad offer. The movie Suckers should be required viewing for podiatry residents.

If OP has no other contract IN HAND (not verbal offer), then trying to negotiate for what is "fair" is fruitless.

As someone who sold used cars, and as someone who worked 3 different informal offers (No contract IN HAND) to compensate me above what the group was paying other associates already in the practice, I would strongly disagree with the above comment.

The more contract you have in hand, then the more upper hand (or foot) you have to negotiate.

You don’t need any contracts to negotiate better compensation from a potential employer. Group X’s contract doesn’t give you any additional leverage in your negotiation with group Y. I guess it could make you more confident in approaching group Y, making your pitch a little more believable. But that’s it. Not to mention, once offered a contract, you don’t have months to sit on it while you START negotiating with other practices. Nobody knows how many offers you have, and you don’t need to be honest when you tell them. You know how many times I had “another buyer” for a car on the lot? Or how many times I had “another offer” from a different group? Lots. Even though I never really did...

You need to be able to say “no” and you need to be able to walk away. Even when you have nothing (at the time) to walk away to. Because there is always some work to be done somewhere. You can do IHS work for 3 months at a time. You can cut nails in nursing homes for a few months. You can take a last minute job outside of your desired area knowing it will only be for a year or two. None of these will pay less than the offers the OP has. He/she has nothing to lose. And even if the OP had a contract IN HAND for one of the 3 jobs listed, I’d still argue he/she has nothing to lose...

 

[G0dFather]

Because going to the OR doesnt make them as much as youd think. 27702 CPT (TAR) is $1100 medicare reimbursement for Medicare in NJ.

I just wanted to take the time and point out how crazy this is ! ..... 1K for the work, expertise, followup and potential complications that can occur with a procedure like this is INSANITY, one could just do a couple of silvers or a mass removal for the same fee ... Whats also insane is that next year all procedures will take a price cut of about 10% across the board, adding further insult to a procedure of that caliber... Whats more insane is devoting 3-4 years for this kind of work, SAD. By ONLY pushing surgery i dont see how this profession can continue to recruit people and thrive in the long run after word of this continues to spread.

 

[HardRoadPaved]

I just wanted to take the time and point out how crazy this is ! ..... 1K for the work, expertise, followup and potential complications that can occur with a procedure like this is INSANITY, one could just do a couple of silvers or a mass removal for the same fee ... Whats also insane is that next year all procedures will take a price cut of about 10% across the board, adding further insult to a procedure of that caliber... Whats more insane is devoting 3-4 years for this kind of work, SAD. By ONLY pushing surgery i dont see how this profession can continue to recruit people and thrive in the long run after word of this continues to spread.

This reimbursement is for any provider type. Medicare does not discriminate between MD/DO/DPM. If you are in NYC then reimbursement goes up to a whopping $1300. So for all those DPM in private practice as an associate..... is it really worth knowing you're only working for 25% of that when you get your "collections bonus?"

The answer is pretty simple. If you want to do these cases you must be paid on an RVU model or have some amazing base salary to make it worth it. You need a large support system like being in an ortho practice or hospital-based group unless you want to be a slave and not have a personal life. If you want to own a solo practice, TAR is just not worth it. If you want to "push surgery" then you must be part of a surgery center or have an in-office ASC.

 

[Pronation]

This reimbursement is for any provider type. Medicare does not discriminate between MD/DO/DPM. If you are in NYC then reimbursement goes up to a whopping $1300. So for all those DPM in private practice as an associate..... is it really worth knowing you're only working for 25% of that when you get your "collections bonus?"

The answer is pretty simple. If you want to do these cases you must be paid on an RVU model or have some amazing base salary to make it worth it. You need a large support system like being in an ortho practice or hospital-based group unless you want to be a slave and not have a personal life. If you want to own a solo practice, TAR is just not worth it. If you want to "push surgery" then you must be part of a surgery center or have an in-office ASC.

Everything you said is 100% the sad, unfortunate truth.

 

[Feli]

... If you want to own a solo practice, TAR is just not worth it. If you want to "push surgery" then you must be part of a surgery center or have an in-office ASC.

Well, the other side of this coin is the community/media prestige you can sometimes spin out of these types of rarer or unique cases. I saw a few docs in my residency area to that to fair effect: made marketing opportunities out of charity missions or rare cases that most of their peers can't and won't do (total talus, TAR, peds stuff, major trauma or recon, etc). It tends to get people talking at the hospital and in the community. Remember the Nip/Tuck episode where they did conjoined twins or the one where they donated $$$ to win the prestigious Plastic Surgery award? 😎

...Now, should we (or anyone) even be doing TARs? I say no. A lot of good surgeons say no. They are a "solution" to a problem that was solved pretty well long ago. If we are going to do them or if a patient is hell bent on having one (despite contrary logic and research outcomes), then shouldn't we funnel them to a few docs who do good volume? Me thinks so. That is neither here nor there, though. Much like gold or god being real or Bitcoin or many things, smart people can debate it until the cows come home.

But still, you can apply it to anything and spin it to your favor with the oddball cases. It is all about perception and being viewed as "the best." I did a 4yo de-syndactyly of multiple digits last month with grafts that despite good coding pays nooooooowhere near what it should (esp when you consider the 30min each for the first couple of f/u visits). A lot of peds stuff is like that. I didn't use it for any promotion since I'm salary govt, and it is already pretty clear to anyone paying attention that I'm the F&A 'big stuff' guy for this rural area. Still, if I were in PP - esp in a competetitive area, you can bet I'd be posting on that on my website/social, submitting an article to the local news, etc. It is all in how you spin it.

 

[DYK343]

Well, the other side of this coin is the community/media prestige you can sometimes spin out of these types of rarer or unique cases. I saw a few docs in my residency area to that to fair effect: made marketing opportunities out of charity missions or rare cases that most of their peers can't and won't do (total talus, TAR, peds stuff, major trauma or recon, etc). It tends to get people talking at the hospital and in the community. Remember the Nip/Tuck episode where they did conjoined twins or the one where they donated $$$ to win the prestigious Plastic Surgery award? 😎

...Now, should we (or anyone) even be doing TARs? I say no. A lot of good surgeons say no. They are a "solution" to a problem that was solved pretty well long ago. If we are going to do them or if a patient is hell bent on having one (despite contrary logic and research outcomes), then shouldn't we funnel them to a few docs who do good volume? Me thinks so. That is neither here nor there, though. Much like gold or god being real or Bitcoin or many things, smart people can debate it until the cows come home.

But still, you can apply it to anything and spin it to your favor with the oddball cases. It is all about perception and being viewed as "the best." I did a 4yo de-syndactyly of multiple digits last month with grafts that despite good coding pays nooooooowhere near what it should (esp when you consider the 30min each for the first couple of f/u visits). A lot of peds stuff is like that. I didn't use it for any promotion since I'm salary govt, and it is already pretty clear to anyone paying attention that I'm the F&A 'big stuff' guy for this rural area. Still, if I were in PP - esp in a competetitive area, you can bet I'd be posting on that on my website/social, submitting an article to the local news, etc. It is all in how you spin it.

I fully agree with the big cases argument. I lose money in the OR especially on larger cases. I would make way more cash if I spent that time in clinic. But to have a busy robust clinic I have to operate as these patients are my referral base.

I convince (or turn away) 2-3 patients to pursue non op care for every 1 patient I sign up for surgery despite them coming to my office looking for a procedure.

Surgical referrals become injections, orthosis, AFOs, multiple visits for follow up on physical therapy, injection, etc etc. Filling my clinic with these low risk patients pays way more $$, can be just as effective as surgery, has minimal or no global, and is much less stressful than a 2hr case.

***If I owned or had stake in a well run surgery center then the argument for low surgical reimbursements may not hold. I'm considering this investment in my future and if anyone has advice on this it would be appreciated.

 

[sloh]

I just wanted to take the time and point out how crazy this is ! ..... 1K for the work, expertise, followup and potential complications that can occur with a procedure like this is INSANITY, one could just do a couple of silvers or a mass removal for the same fee ... Whats also insane is that next year all procedures will take a price cut of about 10% across the board, adding further insult to a procedure of that caliber... Whats more insane is devoting 3-4 years for this kind of work, SAD. By ONLY pushing surgery i dont see how this profession can continue to recruit people and thrive in the long run after word of this continues to spread.

I'm not a pod but man.....this has been an eye opening thread. I share a similar experience. As a PM&R physician, I make more money rounding on patients in the subacute rehab (SNF) setting than interventional pain physicians while working half the hours. It's all volume (35-50 patients/day). I'd imagine this is the case with Ophthalmology as well. Their procedures probably do pay pretty well but they make A LOT of money seeing upwards of 60 patients per day in clinic.

 

[HardRoadPaved]

I'm not a pod but man.....this has been an eye opening thread. I share a similar experience. As a PM&R physician, I make more money rounding on patients in the subacute rehab (SNF) setting than interventional pain physicians while working half the hours. It's all volume (35-50 patients/day). I'd imagine this is the case with Ophthalmology as well. Their procedures probably do pay pretty well but they make A LOT of money seeing upwards of 60 patients per day in clinic.

Always good for a chime in from other specialties. I am assuming you are not in the same group as the joint surgeon so that you are not eating their global periods. Are you a consultant or do you admit to your own service?

For those DPMs out there that want more food for thought. Lets say you have that 25% collection model in PP and you have to round at a hospital. Level 1 follow-up (which most of them are unless you are lying in your coding) is 99231. That is like $40 reimbursement from Medicare. So unless you are seeing a long list, imagine killing your day (driving to the hospital, figure out the maze to patient's room, your patient cant be seen right away bc they are in CT or getting a procedure done or worse on the toilet, then have a note to write on an EMR that youre not familiar with while having a nurse bug you about an order) to collect $10 per patient when all you are doing is making sure the heel wound isnt the patient's source of unexplained leukocytosis. Think about your PP boss getting that 75% of your work for paying for your malpractice and if you're lucky your tank of gas....

 

[sloh]

Always good for a chime in from other specialties. I am assuming you are not in the same group as the joint surgeon so that you are not eating their global periods. Are you a consultant or do you admit to your own service?

For those DPMs out there that want more food for thought. Lets say you have that 25% collection model in PP and you have to round at a hospital. Level 1 follow-up (which most of them are unless you are lying in your coding) is 99231. That is like $40 reimbursement from Medicare. So unless you are seeing a long list, imagine killing your day (driving to the hospital, figure out the maze to patient's room, your patient cant be seen right away bc they are in CT or getting a procedure done or worse on the toilet, then have a note to write on an EMR that youre not familiar with while having a nurse bug you about an order) to collect $10 per patient when all you are doing is making sure the heel wound isnt the patient's source of unexplained leukocytosis. Think about your PP boss getting that 75% of your work for paying for your malpractice and if you're lucky your tank of gas....

Correct, I am not part of the same group as the ortho surgeons who send some of their patients like post-op hip replacements to subacute rehab. I also see patients who have suffered recent strokes, traumatic brain injuries, amputations, or marked deconditioning from hospitalization. The patients are admitted to the SNF's under a primary physician and I am a consultant. I work with the primary and even more so with the therapists focusing on issues related to musculoskeletal, pain, rehab, discharge home. Patient visits and documentation are just so much more efficient in the inpatient setting compared to outpatient which is why I can see upwards of 40-50 patients/day with my workday only lasting about 4-5 hours (including documentation). Because I am not primary, I also do not need to manage the host of other medical issues these patients have.

It is bizarre to many PM&R physicians and residents that this type of work (above) pays so well—and specifically better than interventional pain because pain fellowships are highly sought after since the fluoro procedures confer a pretty good compensation...but that is only if you compare it to a traditional outpatient PM&R MSK practice, not subacute rehab consulting. In an outpatient PM&R MSK clinic the most patients you can probably reasonably see in a day is 20. And ultrasound guided procedures (the bread and butter of outpatient PM&R) reimburse poorly.

 

[dtrack22]

Regardless of compensation model, in general, podiatrist who offer fairly complete (ie toes, foot, ankle) surgical services make more money than those who do not.

I've said this many times before, but inefficient surgery and surgical scheduling is the only way you really lose money doing surgery. Meaning, if you are blocking off an entire day for 1 or 2 cases, AND you would otherwise have a relatively full clinic schedule every day of the week, then you are definitely losing money. If you can do 3 cases in the morning and then have an afternoon clinic, or your OR day has 5-7 cases every week (or maybe you block off a whole day for that volume every other week) then you'll easily come out ahead. Lets say you have 2 bunions with a couple of hammertoes, a fibula orif, a detach/reattach, and a flatfoot. Using medicare rates in my area you get around $1700 for the 2 bunions and 3 hammertoes between the two. $873 for the detach/reattach, $640 for the fibula and a little over $1200 for the flatfoot. Thats just shy of $4500. Lets say your clinic PPV would otherwise be $120, that's 37 clinic patients to equal your surgical reimbursement. And that is assuming you have 30-40 patients just sitting there waiting to be seen because you are so full the other 4 days per week that they can't be scheduled elsewhere. It all really comes down to scheduling efficiencies and weekly clinic volume.

I'm rural and will never have 200 clinic visits per week (40 patients per day for 5 days), but being the only person in a fairly large area who can do, or has any desire to do most foot/ankle cases, 5 cases per week is realistic. Despite being a solo, PP podiatrist, I would lose money if I sent all of those patients out like the community was doing before I arrived. A $600 surgery with a DME device or two, a few post-op xrays, and 3-4 post-op visits in the global is still paying around $150 per encounter (including the day in the OR). That's certainly not great considering the fact that you are doing "surgery" on someone, but it is likely more per visit than you are getting from a lot of your other pathology. And again, I'm at a point where I could see all of my weekly appointments in a 2 day period, so blocking a whole day for surgery in my case still doesn't have a negative impact on my ability to see X number of patients in clinic per week.

So even when you don't factor in things like ancillaries that can come with a practice that offers surgical treatment, the effect on referrals sources (patients and providers) as they learn that you don't do certain things, procedures that can be done in office which can make the reimbursement more financially attractive, etc. I think you'd be hard pressed to find a podiatrist who makes more money by sending out any significant % of surgical pathology. Compared to someone who not only does all of the conservative stuff, but then operates when indicated.

And ultrasound guided procedures (the bread and butter of outpatient PM&R) reimburse poorly

Do you know anything about limits on ultrasound guided injections from payers? I spoke with an ortho group a few years ago who had said that they stopped billing for ultrasound guided knee injections (for example) because insurance was only paying for 1 per year. Or something to that effect. It didn't add enough to the reimbursement to make it worth the added staff hours for pre-auths on all of them and to work claims where the US guided code was rejected. I haven't billed one yet in my new job to see if/what I get paid.